Risk Management Pitfalls, Pain Management, Clinical, Medico Legal

Pain Management in the Emergency Department

From the August 2012 issue of Emergency Medicine Practice, “An Evidence-Based Approach to Traumatic Pain Management in the Emergency Department.” Reprinted with permission. To access your EMRA member benefit of free online access to all EM Practice, Pediatric EM Practice, and EM Practice Guidelines Update issues, go to ebmedicine.net/emra, call 1-800-249-5770, or send e-mail to ebm@ebmedicine.net.

  1. “I thought the patient was just seeking pain medication to get high.”
    Drug-seeking behavior is a difficult problem in the ED, and it is one to which there is not a simple answer. If serious concern exists, an attempt may be made to validate the patient's claims (eg, calling the primary provider, reviewing pharmacy dispensing records, etc), but this is often unsuccessful, and the individual solution may rest with the clinician's judgment or departmental policy.
  2. “I didn't want to give pain medication because I didn't want to mask the examination findings.”
    Appropriate analgesia does not compromise physical examination findings for serious injury and may, in fact, improve the ability to localize painful stimuli. This has been demonstrated reproducibly in the ED setting.
  3. “The patient felt better with pain medication, so I didn't pursue further diagnostic testing.”
    While analgesia may improve comfort, careful attention must still be paid to historical elements (eg, high-energy motor vehicle collision) or examination findings (eg, abdominal tenderness) that may be concerning for serious pathology. A focused examination after analgesia may reveal whether abnormal findings can be evoked in an otherwise comfortable patient.
  4. “There was no radiographic abnormality, so I didn't think the patient needed pain medication.”
    Pain is a subjective experience, and many causes of pain (particularly neuropathic pain) may not provide objective evidence of the level of discomfort.
  5. “I didn't consider regional anesthesia”
    Regional anesthesia is an increasingly popular means of achieving analgesia and decreasing the amount of systemic analgesia required. It is useful to have a repertoire of familiar and useful techniques to augment some scenarios (eg, dental blocks for dental injuries, digital blocks for finger injuries, etc).
  6. “The patient was agitated, and I didn't consider pain as the etiology.”
    Many times patients are unable to communicate their discomfort adequately (eg, intubated or demented patients). Painful conditions should be considered as a cause of increased agitation or delirium.
  7. “The vital signs were normal, so I decided the patient was not in pain.”
    Vital sign abnormalities are not a reliable indicator of pain. In addition to medications that may blunt a response (eg, beta-blockers), each patient's experience and physiologic response may be different, and some patients may experience significant pain without producing abnormal vital signs.
  8. “The patient had opioid dependence, so I used an agonist-antagonist.”
    Some partial agonists (eg, buprenorphine) bind with more affinity than complete agonists. In a patient on a chronic long-acting opioid agonist (eg, methadone), introduction of a partial agonist may displace complete agonists at the receptor site and precipitate a relative withdrawal.
  9. “I had to keep giving him pain medication because he wouldn't calm down.”
    Anxiolysis is an important part of pain control and limiting “wind-up” phenomenon. Often, this can be accomplished by nonpharmacologic means (eg, discussing the patient's concern, covering a wound, distracting a child, or immobilizing a limb).
  10. “The patient was fine when she left for x-ray, but when she returned, she was screaming in pain.”
    ASplinting with radiolucent materials prior to transport or manipulation for imaging helps decrease the pain precipitated by mobilization. In addition, it is reasonable to provide additional analgesia in anticipation of painful procedures or transport.